Provider Demographics
NPI:1932758869
Name:SAMPLE, JESSICA BRIANA
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:BRIANA
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3802
Mailing Address - Country:US
Mailing Address - Phone:909-620-9491
Mailing Address - Fax:909-623-6391
Practice Address - Street 1:1050 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3802
Practice Address - Country:US
Practice Address - Phone:909-623-6391
Practice Address - Fax:909-620-9491
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-155101YA0400X, 101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023173135Medicaid